Bridges Programs

Sometimes the more we need healthcare, the less we can get it. But we believe there should never be “too many barriers” to good healthcare.

To help the two most at-risk populations of women, we have two programs that offer accessible, comprehensive, patient-centered, and accessible care coordination: Bridges to Elders and Bridges to Moms.

Bridges to Elders

Of the 3,000 homeless women in Boston, more than 450 women are over the age of 65.

Being homeless already devastates health outcomes — 94% of homeless women in Boston have multiple complex issues — and the population is well known for the many barriers they face — transportation difficulties, finding food and shelter, mental health issues, trauma, etc. For them, diligent upkeep of health becomes impossible.

And as patients age, as mobility decreases and mental status declines, securing treatment only becomes more difficult. Seemingly simply things like filling prescriptions or keeping appointments cannot be done without help. Those most in need of help, cannot get or even know who to ask for it.

It is for these reasons, in 2013, Healthcare Without Walls founded Bridges to Elders (then Medical Home Without Walls). Our Community Health Workers provide assistance with phone calls, transportation, and accompaniment to visits as well as specialist and laboratory appointments. With the program, elderly women are able to secure a higher level of healthcare.

Take the following story as an example of how the program works. One schizophrenic patient had difficulties remembering to take her medication, and due to an outburst in which she attempted to warn her apartment building of an imagined fire at 4 a.m., she nearly lost her housing. With the Bridges to Elders program, she now receives a medication reminder call from a Community Health Worker each morning, and has since had no issues with her living arrangements.

Some women get help with transportation services. Others simply need the moral and emotional support to overcome depressive attitudes. Our program has seen dramatic increases in health outcomes which have had impressive financial repercussions.

By the Numbers

From the first 6 months of Bridges to Elders

86%

Emergency Department Visits Reduced

$495,000 Savings

77%

Inpatient Visits Reduced

$148,000 Savings

Bridges to Moms

She will not be alone.

Women who are homeless and pregnant face enormous barriers to managing their medical care. These barriers can even prevent bonding with newborns. Transportation, mental illness, domestic violence, surviving — the challenges created by homelessness do not change, but a pregnant woman’s needs grow exponentially. Some expectant mothers cannot make it to their appointments. Some opt to stay in domestic violence situations because they feel they have no choice. And if a newborn is premature and sent to the NICU (for anywhere between 3 weeks to 3 months), some mothers cannot bond with their new children because financial or transportation barriers prevent her from being by her newborn’s side.

In partnership with Brigham and Women’s world-class programs, and with an eye on the success of our Bridges to Elders program, we launched Bridges to Moms in 2016. We meet with the mom during prenatal, peripartum, and postpartum periods to assess not only her medical needs but any other barriers to a healthy birth and a nurturing relationship between mother and child. By providing intensive case management through patient-centered, trusting relationships, we will produce positive outcomes for homeless pregnant and post-partum mothers and their babies as we follow them through pregnancy up to the first year of the child’s life.

Our community Health Outreach Teams provide:

Vital signs checks for mother and fetus

Urine, Strep, Pregnancy, and Diabetes tests

Parenting and newborn education

Counseling and support

Referrals

Accompaniment to appointments

Outside the hospital, we provide:

Housing and home visits

Personal safety

Medical alert bracelets

Transportation

Food sources

Personal supports

Community resources

And it helps!

An independent evaluation performed by the Institute for Community Health shows the benefits of Bridges to Moms on the health of homeless pregnant women and new mothers. Click here to read the full report.